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• SAN JOAQUIN C011rl11' - -- <br /> 0 <br /> NNVIRC)NMENTAL HEALTH DEPAR7'i ENT Retitrn this form by <br /> 104 Ferri�l'eber Avenue,3'd Floor,Stockton,CA 45202-2708 <br /> the 12 `of"c11 month <br /> m <br /> Telephone:(209)4G6-3420 Fax.-(209)464-0118 Web: www,sjgo�•.orglch <br /> W <br /> SFYTAGE CLEANER'S REPORT <br /> Company Name: C 8. C Portable Toilets, Inc- Report for the me (1) o -. yc r_ � <br /> P-O- Box 1523 Signature: t uJ <br /> Company Address: Riverbank, CA 95367 vac�dc <br /> .J <br /> All InfOrm"Eca submitted trust be cum Icte Rccurtite mud legible (R) Rw-motrtuL <br /> ADDRESS NVHERE WORK 11'AS DONE GALLONS (G) CREASIET .u' NAMES.h•T <br /> e�OF TREATM <br /> DATE ilAA)Lt OF BUSINESS OR <br /> O rump" PROPERTY OWNER )LEASE INCLUDE STREET W. DIAECTIOK, STREET NAME AND CITY PUMPEDC) atEnRGL FACILffY <br /> N a: /2— A 2 r <br /> (T) -i <br /> a) a <br /> m = acr <br /> e cih <br /> OD z7� <br /> R <br /> O ► Z <br /> CLl cl <br /> Z l <br /> Z <br /> O \ City <br /> (Y <br /> H <br /> z cis <br /> LLJ <br /> f t c, l�2 <br /> Ad City <br /> W J c'rV <br /> r� <br /> � City o <br /> �0 z <br /> L m Cay <br /> CD <br /> W <br /> U v City - <br /> U C4 <br /> n"' o <br /> City - <br /> CLy <br /> O m Cite' <br /> m _ <br /> �t - <br /> F— <br /> Cuy <br /> Lr) IT RD `12-Ila > <br /> O <br /> ?;!J 0/011 <br /> O <br /> N <br /> Q <br />